NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) Non-Hodgkin s Lymphomas Version 2.2015 NCCN.org Continue
Supportive Care for NHL
Tumor Lysis Syndrome (TLS) Laboratory hallmarks of TLS: High potassium High uric acid High phosphorous Low calcium Symptoms of TLS: Nausea and vomiting, shortness of breath, irregular heartbeat, clouding of urine, lethargy, and/or joint discomfort. High-risk features Histologies of Burkitt Lymphoma and Lymphoblastic Lymphoma; occasionally patients with DLBCL and CLL Spontaneous TLS Elevated WBC Bone marrow involvement Pre-existing elevated uric acid Ineffectiveness of allopurinol Renal disease or renal involvement by tumor Treatment of TLS: TLS is best managed if anticipated and treatment is started prior to chemotherapy. Centerpiece of treatment includes Rigorous hydration Management of hyperuricemia Frequent monitoring of electrolytes and aggressive correction is essential First-line and at retreatment Allopurinol beginning 2 3 days prior to chemotherapy and continued for 10 14 days or Rasburicase is indicated for patients with any of the following risk factors: - presence of any high-risk feature - urgent need to initiate therapy in a high-bulk patient - situations where adequate hydration may be difficult or impossible - Acute renal failure One dose of rasburicase is frequently adequate. Doses of 3 6 mg are usually effective. Redosing should be individualized. If TLS is untreated, its progression may cause acute kidney failure, cardiac arrhythmias, seizures, loss of muscle control, and death. Supportive Care for NHL continued on next page 1 of 3
For other immunosuppressive situations, see NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections. Monoclonal Antibody Therapy and Viral Reactivation Anti-CD20 Antibody Therapy Hepatitis C virus (HCV): Hepatitis B virus (HBV): New evidence from large epidemiology studies, molecular biology Hepatitis B surface antigen (HBsAg) and Hepatitis B core antibody research, and clinical observation supports an association of HCV ( HBcAb) testing for all patients receiving anti-cd20 antibody therapy and B-cell NHL. Recently approved direct-acting antiviral agents Quantitative hepatitis B viral load by PCR and surface antibody only (DAA) for chronic carriers of HCV with genotype 1 demonstrated a if one of the screening tests is positive high rate of sustained viral responses. Note: Patients receiving IV immunoglobulin (IVIG) may be HBcAbpositive as a consequence of IVIG therapy. According to the American Association for the Study of Liver Low-grade B-cell NHL Prophylactic antiviral therapy with entecavir is recommended for any Diseases, combined therapy with DAA should be considered in patient who is HBsAg-positive and receiving anti-lymphoma therapy. asymptomatic patients with HCV genotype 1 since this therapy If there is active disease (PCR+), it is considered treatment/ can result in regression of lymphoma. management and not prophylactic therapy. In cases of HBcAb Aggressive B-cell NHL positivity, prophylactic antiviral therapy is preferred; however, if there Patients should be initially treated with chemoimmunotherapy is a concurrent high-level hepatitis B surface antibody, these patients regimens according to NCCN Guidelines for NHL. may be monitored with serial hepatitis B viral load. Liver functional tests and serum HCV RNA levels should be Entecavir is preferred based on Huang YH, et al. J Clin Oncol closely monitored during and after chemoimmunotherapy for 2013;31:2765-2772; Huang H, et al. J Clin Oncol 2013;31:Abstract development of hepatotoxicity. 8503 Antiviral therapy should be considered in patients in complete remission after completion of lymphoma therapy. Avoid lamivudine due to risks of resistance development. Other antivirals including adefovir, telbivudine, and tenofovir are proven active treatments and are acceptable alternatives. Anti-CD20 Antibody Therapy and Brentuximab Vedotin hepatitis B viral load monthly through t Progressive multifocal leukoencephalopathy (PML): Caused by the JC virus and is usually fatal. Diagnosis made by PCR of CSF and in some cases brain biopsy. No known effective treatment. Clinical indications may include changes in behavior such as confusion, dizziness or loss of balance, difficulty talking or walking, and vision problems. Monitor with PCR reatment and every 3 months thereafter If viral load is consistently undetectable, treatment is considered prophylactic If viral load fails to drop or previously undetectable PCR becomes positive, consult hepatologist and discontinue anti-cd20 antibody therapy Maintain prophylaxis up to 12 mo after oncologic treatment ends Consult with hepatologist for duration of therapy in patient with active HBV Supportive Care for NHL continued on next page 2 of 3
Monoclonal Antibody Therapy and Viral Reactivation (continued) Anti-CD52 Antibody Therapy: Alemtuzumab Cytomegalovirus (CMV) reactivation: The current appropriate management is controversial; some NCCN Member Institutions use ganciclovir (oral or IV) preemptively if viremia is present, others only if viral load is rising. CMV viremia should be measured by quantitative PCR at least every 2 to 3 weeks. Consultation with an infectious disease expert may be necessary. See NCCN Guidelines for Prevention and Treatment of Cancer- Related Infections. Rituximab Rapid Infusion If no infusion reactions were experienced with prior cycle of rituximab, a rapid infusion over 90 minutes can be used. Methotrexate and Glucarpidase Consider use of glucarpidase if significant renal dysfunction and methotrexate levels are >10 microm beyond 42 to 48 hours. Leucovorin remains a component in the treatment of methotrexate toxicity and should be continued for at least 2 days following glucarpidase administration. However, be aware that leucovorin is a substrate for glucarpidase, and therefore should not be administered within two hours prior to or following glucarpidase. 3 of 3